oncothesis

Pedicled Perforator Flaps in Breast : a new concept

Authors M. Hamdi, F. Thiessen, H. Depypere

Key words Breast , surgery, pedicled perforator flaps

Summary of the breast volume, pedicled perforator flaps The treatment of early stage breast cancer with should be the method of choice. The technique tumorectomy followed by postoperative radio- is indicated as a multidisciplinary approach for therapy, often referred to as breast conservation patients with (T1-T2) tumors. The concept can therapy (BCT), may be considered as an oncologi- be safely applied to a large spectrum of clinical cal equivalent to mastectomy in selected cases. indications with lower complication rate and It can be recommended to perform an immedi- minimal donor site morbidity because it spares ate breast reconstruction whenever it is feasi- the latissimus dorsi muscle. This article sum- ble and indicated. Depending on the amount marizes a scientific thesis about the pedicled of gland resection and the size of the breast, perforator flaps, which have been presented as different techniques can be applied. In partial a new concept in breast surgery. breast reconstruction for defects less than 30% (BJMO 2008;vol 2;5:288-92)

Introduction metric breast reconstruction. Koshima et al were the During the last decades there has been a tremen- first to report the clinical use of the abdominal skin dous evolution in reconstructive breast surgery and fatty tissue based on the deep inferior epigastric resulting in a myriad of techniques and applicati- artery perforator (DIEAP) without sacrificing the ons. The field of reconstructive surgery has taken rectus muscle.1 Since that time the DIEAP flap has a significant leap forward with the introduction of been the gold standard for post-mastectomy recon- perforator flap surgery. In perforator flap surgery, struction.2-6 The main advantage of the DIEAP flap, only skin and is utilized for as compared to the rectus abdominis musculocuta- reconstruction of defects in a more precise fashion neous (TRAM) flap, is the complete preservation of with preservation of , muscles and ac- the rectus abdominis muscle and the anterior rectus cording to the basic plastic surgical principle of sheath in order to reduce the incidence of abdominal ‘replacing like with like’. Koshima et al introduced morbidity such as bulging, hernia and weakness.3-6 the terminology ‘perforator flap’ in 1989 Figure( 1 In 1995, Angrigiani et al introduced the concept of on page 288).1 The most important advantage of raising the cutaneous portion of the latissimus dorsi the perforator flaps is that the muscle can be left flap without the muscle.7 Since then, the thoracodor- in its native place to serve its original function and sal artery perforator (TDAP) flap was reported as a minimize donor site morbidity. free flap for reconstruction after trauma or burns.8,9 During the 1990s, the use of perforator flaps for However, the use of a pedicled TDAP flap in breast autologous breast reconstruction was developed in reconstruction was first reported by our group.10 Do- an effort to perform a safe, reliable, reproducible nor site morbidity after raising a pedicled perforator reconstruction with low donor site morbidity. The flap is reduced to an absolute minimum since the skin and subcutaneous fatty tissue of the lower ab- underlying muscles are left intact with their func- domen provides adequate volume to achieve sym- tional motor innervation. During the harvesting of

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Fascia Table 1. Indications of pedicled perforator flaps

Skin Immediate or delayed partial breast reconstruction following tumorectomy/quadrantectomy.

Direct Muscle Post-mastectomy breast reconstruction in branch combination with an implant. Muscle perforator Breast augmentation with autologous tissue or Main Pedicle Septal perforator correction of congenital asymmetry. Reconstruction of shoulder and thoracic defects after oncological resections.

Figure 1. different types of perforators.

a perforator flap, the surgeon may change his initial surgical dilemma in the treatment of breast cancer. plan and choose a different perforator, which arises This dilemma arises because, on one hand wider from another vascular pedicle in the same territory. excision is necessary to provide clear margins and Wei and Mardiri referred to this strategy as free style better local control of breast cancer, whereas on the flap harvesting.11 Based on this concept, Hamdi et al other hand sparing as much tissue as possible is ne- reported several pedicled perforator flaps used in cessary for defect closure and the resulting aesthetic different indications. outcome.15,16 In this thesis, the pedicled perforator flaps, which Immediate reconstruction whenever it is feasible and are considered as second generation perforator flaps, indicated is preferred. To obtain a satisfactory aes- have been presented as a new concept in breast sur- thetic result, the created cavity should be filled with gery. This concept can be safely applied to a large local or distant tissues before starting the irradiation, spectrum of clinical indications with lower compli- as operating on irradiated breasts has high complica- cation rates as compared to the classical latissimus tion rates and often yields poor aesthetic results.15-18 dorsi (LD) muscle flaps. During immediate reconstruction, the breast can be manipulated prior to irradiation, resulting in a lo- wer complication rate and improved outcome.10,15-18

Classification and indications of pedicled This technique is mainly indicated for 1T -T 2 breast perforator flaps tumors. Depending on the amount of gland resec- Based on the ‘Ghent Consensus’, the pedicled perfo- tion and the size of the breast, different techniques rator flaps that are commonly used for breast or tho- can be applied. When the defect does not exceed racic reconstruction can be classified as follows:12 30% of the breast volume, pedicled perforator flaps • the thoracodorsal artery perforator (TDAP) flap should be the method of choice in partial breast re- • the intercostal artery perforator (ICAP) flap construction. Pedicled perforator flap options inclu- • the serratus anterior artery perforator (SAAP) flap de: the Thoraco-Dorsal Artery Perforator (TDAP) • the superior epigastric artery perforator (SEAP) flap flap, the Lateral Intercostal Artery Perforator (LI- Partial breast reconstruction is an original indica- CAP flap), the Serratus Anterior Artery Perforator tion for the pedicled perforator flaps. Other indica- (SAAP) flap and the Superior Epigastric Artery Per- tions are summarized in Table 1. forator (SEAP) flap.19-22 In the presented clinical se- ries, the TDAP flap was used most often Figure( 2). As previous surgery or radiotherapy can damage the Partial breast reconstruction with pedicled thoracodorsal vessels, the vessels should be checked perforator flaps before the operation. Preoperative location of the The treatment of early stage breast cancer by par- perforator is essential for safe and straightforward tial mastectomy followed by postoperative radiothe- flap dissection. Careful preoperative perforator rapy, often referred to as breast conservation therapy mapping either by Doppler, or more recently using (BCT), may be considered as an oncological equiva- a multi-detector CT scan is one of the most impor- lent to mastectomy in selected cases.13,14 tant requirements for successful flap dissection.23 Most conditions that lead to the described poor aes- The surgical technique of flap harvesting is gene- thetic outcome following BCT are a result of the rally accepted as a safe, reliable and reproducible

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Figure 2. A case of a 53 year-old patient with a tumor (invasive ductal carcinoma), which was located in the right supero-la- teral quadrant. (A) Preoperative views, (B) A pedicled (21 x 8 cm) TDAP flap was designed with a horizontal orientation over the lateral thoracic region with two perforators detected by unidirectional Doppler probe. (C) Intra-operative view shows dissection of one perforator (arrow) through the split LD muscle. The TD branches to the LD muscle are spared. (D) The flap was completely de-epithelialized. (E) Setting the flap into the post-quadrantectomy defect (specimen weight 98g). (F) Postoperative views at 18 months postoperatively. (G)The donor site. From M. Hamdi Pedicled Perforator Flaps Reconstruction. In eds. Losken A, Hamdi M. Partial Breast Reconstruction: Techni- ques in Oncoplastic Surgery. St. Louis: Quality Medical Publishing. In press, Oct 2008. (*Permission for figures obtained from publisher QMP) technique. The ability to convert the TDAP flap to ting the pedicled TDAP flap showed that the do- different muscle sparing type of flaps in the case of nor site morbidity was reduced to an absolute mi- an unfavorable anatomical situation is essential to nimum.24 In addition, seroma formation, which is a avoid flap-related complications.19 major postoperative complication after harvesting a Functional evaluation of the shoulder after harves- latissimus dorsi flap, was not observed in any of the

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Key messages for clinical practice

1. Oncoplastic breast surgery is a nice illustration of the multidisciplinary approach to breast cancer, which offers wide and safe tumor resection together with an immediate breast reconstruction.

2. The pedicled TDAP flap is a reliable and safe flap and it should replace the classical latissimus dorsi flap in many indications in breast surgery.

3. Donor site morbidity after harvesting a TDAP flap is reduced to an absolute minimum.

4. New perforator flaps such as the LICAP, SAAP and SEAP represent the next era in perforator flaps.

donor sites of the TDAP flap.24 References The LICAP flap has also been widely investigated 1. Koshima I, Soeda S. Inferior epigastric artery skin flaps with- in this thesis. The anatomy of the flap with the lo- out rectus abdominis muscle. Br J Plast Surg 1989;42:645. cations, distributions and relationships to the latis- 2. Allen R, Treece P. Deep inferior epigastric perforator flap simus dorsi muscle and the serratus anterior vessels for breast reconstruction. Ann Plast Surg 1994;32:32. has been described.20-21 3. Hamdi M, Weiler-Mithoff E, Webster M. Deep inferior epi- The location of the deformity influences the choice gastric perforator flap in breast reconstruction: experience of flaps. Due to insufficient reach, laterally-based with the first 50 flaps. Plast Reconstr Surg 1999;103:86-95. pedicled flaps (i.e., LD, LICAP, TDAP, lateral tho- 4. Blondeel P. One hundred free DIEP flap breast reconstruc- racic) are generally unsuitable for reconstruction of tions: a personal experience. Br J Plast Surg 1999;52:104-11. large defects of the medial breast quadrants. Howe- 5. Blondeel P, Vanderstraeten G, Monstrey S et al. The donor ver, the pedicled Superior Epigastric Artery Perfo- site morbididty of free DIEP flapsand free TRAM flaps for rator (SEAP) flap can be used in selected cases with breast reconstruction. Br J Plast Surg 1997; 50:322. small size defects.22 The use of this SEAP flap in 6. Hamdi M, Blondeel P, Van Landuyt K, et al. Bilateral breast reconstruction has been also described in the autogenous breast reconstruction using perforator free presented thesis. flaps: a single center’s experience. Plast Reconstr Surg 2004;114 (1): 83-9. 7. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi mus- Conclusion culocutaneous flap without muscle. Plast Reconstr Surg During the past 7 years, the concept of pedicled per- 1995;96:1608-14. forator flaps has significantly refined the practice in 8. Van Landuyt K, Hamdi M, Blondeel P, et al. The compound breast surgery. Harvesting a flap without sacrificing thoracodosal perforator flap in the treatment of combined the underlying muscle or the functional motor ner- soft-tissue defects of sole and dorsum of the foot. Br J Plast ves characterizes this technique. Perforator flaps Surg 2005;58(3):371-811. aim to reduce donor site morbidity to an absolute 9. Hamdi M, Van Landuyt K, Monstrey S, et al. A clinical minimum, respecting one of the main adagios in experience with perforator flaps in the coverage of exten- medicine: ‘primum non nocere’. Partial breast recon- sive defects of the upper extremity. Plast Reconstr Surg struction is an original indication for the pedicled 2004;113 (4 ):1175-83. TDAP flap. This technique is a nice illustration of 10. M. Hamdi, K. Van Landuyt, S. Monstrey et al. Pedicled the multidisciplinary approach for patients with perforator flaps in breast reconstruction: a new concept. Br breast cancer (tumors of less than 3 cm diameter). J Plast Surg 2004;57(6):644-52. The close cooperation between the breast surgeon 11. Wei F, Mardini S. Free-style free flaps. Plast Reconstr Surg who does the resection and the plastic surgeon that 2004;114(4):910-6. performs the reconstruction has produced the best 12. Blondeel P, Van Landuyt K, Monstrey S, Hamdi M, model in oncoplastic surgery. Matton G, Allen R, et al. The “Ghent” consensus on perfora-

291 v o l . 2 i s s u e 5 - 2008 BELGIAN JOURNAL OF MEDICAL ONCOLOGY tor flap terminology: preliminary definitions. Plast Reconstr Multi-Detector CT Scan Images in Preoperative Perforator Surg 2003;112(5):1378-83. Mapping and Clinical Applications of the Superior Epigastric 13. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year fol- Artery Perforators Flaps. J Plast Reconstr Asthet Surg 2008; low-up of a randomized study comparing breast-conserving in press. surgery with radical mastectomy for early breast cancer. N 23. Hamdi M, Van Landuyt K, Van Hedent E, et al. Advances in Engl J Med 2002;347:1227-1232. autogenous breast reconstruction: the role of preoperative 14. Fisher B, Anderson S, Bryant J. Twenty-year follow-up of mapping. Ann Plast Surg 2007; 58(1):18-26. a randomized trial comparing total mastectomy, lumpec- 24. Hamdi M, Decorte T, Demuynck M, et al. Shoulder func- tomy, and lumpectomy plus irradiation for the treatment of tion after harvesting a thoracodorsal artery perforator flap. invasive breast cancer. N Engl J Med 2002;347:1233-1241. Plast Reconstr Surg 2008; in press. 15. Berrino P, Campora E, Santi P. Postquadrantectomy breast deformities: classification and techniques of surgical correc- Correspondence address tion. Plast Reconstr Surg 1987;79:567-571. 16. Clough K, Cuminet J, Fitoussi A, et al. Cosmetic seque- lae after conservative treatment for breast cancer: classi- Authors: M. Hamdi1, F. Thiessen1, H. Depypere2 fication and results of surgical correction. Ann Plast Surg 1Department of Plastic and Reconstructive Surgery, 1998;41:471-481. University Hospital Ghent, Ghent, Belgium. 2Breast 17. Hamdi M, Wolfli J, Van Landuyt K. Partial mastectomy and Menopause Clinic, University Hospital Ghent, reconstruction. Clin Plast Surg 2007;34:51-62. Ghent, Belgium 18. Kronowitz S, Feledy J, Hunt K, et al. Determining the opti- mal approach to breast reconstruction after partial mastec- Please send all correspondence to: tomy. Plast Reconstr Surg 2006;117:1-11. Prof. Dr. M. Hamdi 19. Hamdi M, Van Landuyt K, Hijjawi J, et al. Surgical Tech- Department of Plastic and Reconstructive Surgery nique in Pedicled Thoracodorsal Artery Perforator Flaps: A University Hospital Ghent Clinical Experience with 99 patients. Plast Reconstr Surg De Pintelaan 185, 2K12C 208:121(5):1632-41. B-9000 Ghent 20. Hamdi M, Van Landuyt K, de Frene D, et al. The versatility Belgium of the intercostal artery perforator ICAP flap. J Plast Recon- Tel: 0032 (0)9 332 60 40 str Aesth Surg 2006;59(6):644-52. Fax: 0032 (0)9 332 38 99 21. Hamdi M, Spano A, Van Landuyt K, et al. The lateral [email protected] intercostal artery perforators: anatomical study and clini- cal applications in breast surgery. Plast Reconstr Surg Conflicts of interest: the authors have nothing to 2008;121(2):389-96. disclose and indicate no potential conflicts of interest. 22. Hamdi M, Van Landuyt K, Ulens S, et al. The Role of the

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